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Pons-Belda OD, Alonso-Álvarez MA, González-Rodríguez JD, Mantecón-Fernández L, Santos-Rodríguez F. Mineral Metabolism in Children: Interrelation between Vitamin D and FGF23. Int J Mol Sci 2023; 24:ijms24076661. [PMID: 37047636 PMCID: PMC10094813 DOI: 10.3390/ijms24076661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 03/29/2023] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
Fibroblast growth factor 23 (FGF23) was identified at the turn of the century as the long-sought circulating phosphatonin in human pathology. Since then, several clinical and experimental studies have investigated the metabolism of FGF23 and revealed its relevant pathogenic role in various diseases. Most of these studies have been performed in adult individuals. However, the mineral metabolism of the child is, to a large extent, different from that of the adult because, in addition to bone remodeling, the child undergoes a specific process of endochondral ossification responsible for adequate mineralization of long bones’ metaphysis and growth in height. Vitamin D metabolism is known to be deeply involved in these processes. FGF23 might have an influence on bones’ growth as well as on the high and age-dependent serum phosphate concentrations found in infancy and childhood. However, the interaction between FGF23 and vitamin D in children is largely unknown. Thus, this review focuses on the following aspects of FGF23 metabolism in the pediatric age: circulating concentrations’ reference values, as well as those of other major variables involved in mineral homeostasis, and the relationship with vitamin D metabolism in the neonatal period, in vitamin D deficiency, in chronic kidney disease (CKD) and in hypophosphatemic disorders.
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Affiliation(s)
| | | | | | | | - Fernando Santos-Rodríguez
- Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
- Department of Medicine, Faculty of Medicine, University of Oviedo, 33003 Oviedo, Spain
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2
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Tain YL, Hsu CN. Cardiovascular Risks of Hypertension: Lessons from Children with Chronic Kidney Disease. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1650. [PMID: 36360378 PMCID: PMC9688449 DOI: 10.3390/children9111650] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 09/29/2023]
Abstract
Hypertension is the most common complication of chronic kidney disease (CKD) in children, having a strong association with subsequential cardiovascular disease (CVD). In pediatric CKD, a considerable percentage of children with hypertension are undiagnosed or undertreated. Prior research has evaluated structural and functional markers of subclinical CVD and biomarkers in adults with CKD, while ideal biomarkers in pediatrics are still insufficiently studied. The ultimate goal of this review is to summarize what is currently known about state of hypertension, cardiovascular risk factors, and potential CVD markers/biomarkers in children with pre-dialysis CKD. We discuss omics-related biomarkers and the pathophysiologic processes of endothelial dysfunction, kidney injury, oxidative stress and inflammation that are classified by specific biomarkers. Moreover, we illustrate the existing challenges and highlight the paucity of pediatric CKD research to evaluate these CVD biomarkers for future clinical pediatric practice. Thus, achieving clinical utility of CVD biomarkers for use in pediatric CKD remains a significant challenge requiring additional efforts.
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Affiliation(s)
- You-Lin Tain
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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3
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Singh G, Mishra OP, Abhinay A, Agarwal V, Mishra SP, Dwivedi AD, Singh A, Prasad R, Mishra RN. Fibroblast Growth Factor 23 Level and Cardiovascular Parameters in Children with Chronic Kidney Disease. Indian J Pediatr 2022; 89:865-871. [PMID: 34767187 DOI: 10.1007/s12098-021-03927-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 06/09/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To find out the serum fibroblast growth factor 23 (FGF-23) levels in different grades of CKD, and the prevalence of abnormal left ventricular mass index (LVMI), carotid intima-medial thickness (cIMT), and central pulse wave velocity (cPWV) and the risk factors including FGF-23 for these abnormalities. METHODS Fifty-nine patients of CKD with G2 to G5, aged 2-18 y were included. The LVMI, cIMT, and cPWV were measured using standard techniques, and serum intact FGF-23 levels were estimated at enrollment. RESULTS Median FGF-23 levels were significantly raised in all the grades of CKD than controls (p < 0.001), and also in G4 and G5 in comparison to G2&3 and in G5D than G5. Increased LVMI in 42 (71.2%), elevated cIMT in 30 (57.7%), and cPWV in 14 (26.9%) patients were found. The FGF-23 showed significant negative correlation with eGFRcr and positive with serum iPTH, phosphate and alkaline phosphatase levels, but had no correlations with LVMI, cIMT SDS, and cPWV SDS. Only systolic BP SDS (odds ratio 1.5, 95% CI 1.008-2.231, p = 0.046) was observed as a significant predictor for increased cIMT, while no variables had any association with abnormal LVMI and cPWV. CONCLUSIONS Serum FGF-23 showed higher levels with increasing grades of CKD, but no significant association with cardiovascular parameters. Systolic BP SDS was found as a significant risk factor for increased cIMT in children with CKD.
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Affiliation(s)
- Gaurav Singh
- Division of Pediatric Nephrology, Department of Pediatrics, Banaras Hindu University, Varanasi, Uttar Pradesh, 221005, India
| | - Om P Mishra
- Division of Pediatric Nephrology, Department of Pediatrics, Banaras Hindu University, Varanasi, Uttar Pradesh, 221005, India.
| | - Abhishek Abhinay
- Division of Pediatric Nephrology, Department of Pediatrics, Banaras Hindu University, Varanasi, Uttar Pradesh, 221005, India
| | - Vikas Agarwal
- Department of Cardiology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Surendra P Mishra
- Department of Biochemistry, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Amitnandan D Dwivedi
- Department of Radiodiagnosis and Imaging, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ankur Singh
- Division of Pediatric Nephrology, Department of Pediatrics, Banaras Hindu University, Varanasi, Uttar Pradesh, 221005, India
| | - Rajniti Prasad
- Division of Pediatric Nephrology, Department of Pediatrics, Banaras Hindu University, Varanasi, Uttar Pradesh, 221005, India
| | - Rabindra N Mishra
- Center of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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4
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Ferraro S, Biganzoli G, Calcaterra V, Zuccotti G, Biganzoli EM, Plebani M. Fibroblast growth factor 23: translating analytical improvement into clinical effectiveness for tertiary prevention in chronic kidney disease. Clin Chem Lab Med 2022; 60:1694-1705. [PMID: 36008874 DOI: 10.1515/cclm-2022-0635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/22/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Fibroblast growth factor 23 (FGF23) plays a key role in the pathophysiology of chronic kidney disease (CKD) and of the associated cardiovascular diseases, ranking on the crossroads of several evolving areas with a relevant impact on the health-care system (ageing, treatment of CKD and prevention from cardiovascular and renal events). In this review, we will critically appraise the overall issues concerning the clinical usefulness of FGF23 determination in CKD, focusing on the analytical performances of the methods, aiming to assess whether and how the clinical introduction of FGF23 may promote cost-effective health care policies in these patients. CONTENT Our comprehensive critical appraisal of the literature revealed that we are currently unable to establish the clinical usefulness of FGF23 measured by ELISA in CKD, as stability issues and suboptimal analytical performances are the major responsible for the release of misleading results. The meta-analytical approach has failed to report unambiguous evidence in face of the wide heterogeneity of the results from single studies. SUMMARY AND OUTLOOK Our review has largely demonstrated that the clinical usefulness depends on a thorough analytical validation of the assay. The recent introduction of chemiluminescent intact-FGF23 (iFGF23) assays licensed for clinical use, after passing a robust analytical validation, has allowed the actual assessment of preliminary risk thresholds for cardiovascular and renal events and is promising to capture the iFGF23 clinically relevant changes as a result of a therapeutic modulation. In this perspective, the analytical optimization of FGF23 determination may allow a marriage between physiology and epidemiology and a merging towards clinical outcomes.
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Affiliation(s)
- Simona Ferraro
- Endocrinology Laboratory Unit, "Luigi Sacco" University Hospital, Milan, Italy
| | - Giacomo Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
| | - Valeria Calcaterra
- Department of Internal Medicine, University of Pavia, Pavia, Italy.,Pediatric Department, "V. Buzzi" Children's Hospital, Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, "V. Buzzi" Children's Hospital, Milan, Italy.,Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Elia Mario Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, Padova, Italy
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5
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Sellier AB, Seiler-Mußler S, Emrich IE, Böhm M, Fliser D, Zawada AM, Heine GH. FGFR4 and Klotho Polymorphisms Are Not Associated with Cardiovascular Outcomes in Chronic Kidney Disease. Am J Nephrol 2021; 52:808-816. [PMID: 34673637 DOI: 10.1159/000519274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/17/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION High plasma fibroblast growth factor 23 (FGF-23) predicts cardiovascular events in chronic kidney disease (CKD) patients. Experimental evidence suggests FGF receptor 4 (FGFR4) activation by FGF-23, and deficiency of the soluble form of its co-receptor Klotho promotes left-ventricular hypertrophy (LVH). To evaluate the clinical relevance of these findings, a Mendelian randomization study analyzed the association of genetic variants of FGFR4 and Klotho with echocardiographic parameters and cardiac events in CKD patients. METHODS The prospective Cardiovascular and Renal Outcome in CKD 2-4 Patients-The Fourth Homburg Evaluation study recruited CKD G2-G4 patients, of whom 519 consented to SNP genotyping (FGFR4: rs351855; Klotho: rs9536314). Echocardiographic examinations at baseline and 5 years later assessed prevalence of LVH by measurement of left-ventricular mass index (LVMI). Patients were followed for 5.1 ± 2.1 years for the primary endpoints of cardiac decompensation and atherosclerotic cardiovascular disease (ASCVD). RESULTS Carriers of the different alleles did neither differ in baseline LVMI (rs351855: p = 0.861; rs9536314: p = 0.379) nor in LVMI changes between baseline and follow-up (rs351855: p = 0.181; rs9536314: p = 0.995). Hundred and four patients suffered cardiac decompensation, and 144 patients had ASCVD. Time to cardiac decompensation (rs351855: p = 0.316; rs9536314: p = 0.765) and ASCVD (p = 0.508 and p = 0.800, respectively) did not differ between carriers of different alleles. DISCUSSION/CONCLUSION rs351855 and rs9536314 were not associated with LVMI or cardiac events. These findings do not provide evidence for a relevant clinical role of either FGFR4 stimulation or soluble form of Klotho deficiency in LVH development.
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Affiliation(s)
- Alexander B Sellier
- Department of Internal Medicine IV-Nephrology and Hypertension, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Sarah Seiler-Mußler
- Department of Internal Medicine IV-Nephrology and Hypertension, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
- Vauban Praxis, Saarlouis, Germany
| | - Insa E Emrich
- Department of Internal Medicine III-Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Michael Böhm
- Department of Internal Medicine III-Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Danilo Fliser
- Department of Internal Medicine IV-Nephrology and Hypertension, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Adam M Zawada
- Department of Internal Medicine IV-Nephrology and Hypertension, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gunnar H Heine
- Department of Internal Medicine IV-Nephrology and Hypertension, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
- Department of Internal Medicine II, Agaplesion Markus Krankenhaus, Frankfurt, Germany
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6
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Leifheit-Nestler M, Haffner D. How FGF23 shapes multiple organs in chronic kidney disease. Mol Cell Pediatr 2021; 8:12. [PMID: 34536161 PMCID: PMC8449753 DOI: 10.1186/s40348-021-00123-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is associated with distinct alterations in mineral metabolism in children and adults resulting in multiple organ dysfunctions. Children with advanced CKD often suffer from impaired bone mineralization, bone deformities and fractures, growth failure, muscle weakness, and vascular and soft tissue calcification, a complex which was recently termed CKD-mineral and bone disorder (CKD-MBD). The latter is a major contributor to the enhanced cardiovascular disease comorbidity and mortality in these patients. Elevated circulating levels of the endocrine-acting phosphaturic hormone fibroblast growth factor (FGF) 23 are the first detectable alteration of mineral metabolism and thus CKD-MBD. FGF23 is expressed and secreted from osteocytes and osteoblasts and rises, most likely due to increased phosphate load, progressively as kidney function declines in order to maintain phosphate homeostasis. Although not measured in clinical routine yet, CKD-mediated increased circulating levels of FGF23 in children are associated with pathological cardiac remodeling, vascular alterations, and increased cognitive risk. Clinical and experimental studies addressing other FGF23-mediated complications of kidney failure, such as hypertension and impaired bone mineralization, show partly conflicting results, and the causal relationships are not always entirely clear. This short review summarizes regulators of FGF23 synthesis altered in CKD and the main CKD-mediated organ dysfunctions related to high FGF23 levels.
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Affiliation(s)
- Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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7
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Grund A, Sinha MD, Haffner D, Leifheit-Nestler M. Fibroblast Growth Factor 23 and Left Ventricular Hypertrophy in Chronic Kidney Disease-A Pediatric Perspective. Front Pediatr 2021; 9:702719. [PMID: 34422725 PMCID: PMC8372151 DOI: 10.3389/fped.2021.702719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/05/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiovascular diseases (CVD) are a hallmark in pediatric patients with chronic kidney disease (CKD) contributing to an enhanced risk of all-cause and CV morbidity and mortality in these patients. The bone-derived phosphaturic hormone fibroblast growth factor (FGF) 23 progressively rises with declining kidney function to maintain phosphate homeostasis, with up to 1,000-fold increase in patients with kidney failure requiring dialysis. FGF23 is associated with the development of left ventricular hypertrophy (LVH) and thereby accounts to be a CVD risk factor in CKD. Experimentally, FGF23 directly induces hypertrophic growth of cardiac myocytes in vitro and LVH in vivo. Further, clinical studies in adult CKD have observed cardiotoxicity associated with FGF23. Data regarding prevalence and determinants of FGF23 excess in children with CKD are limited. This review summarizes current data and discusses whether FGF23 may be a key driver of LVH in pediatric CKD.
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Affiliation(s)
- Andrea Grund
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hanover, Germany.,Paediatric Research Centre, Hannover Medical School, Hanover, Germany
| | - Manish D Sinha
- Department of Paediatric Nephrology, King's College London, Evelina London Children's Hospital, London, United Kingdom
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hanover, Germany.,Paediatric Research Centre, Hannover Medical School, Hanover, Germany
| | - Maren Leifheit-Nestler
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hanover, Germany.,Paediatric Research Centre, Hannover Medical School, Hanover, Germany
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8
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Kim JY, Lee Y, Kang HG, Ha IS, Cheong HI, Choi HJ, Han KH, Kim SH, Cho MH, Shin JI, Lee JH, Park YS, Cho H. Left-ventricular diastolic dysfunction in Korean children with chronic kidney disease: data from the KNOW-Ped CKD study. BMC Nephrol 2020; 21:533. [PMID: 33297989 PMCID: PMC7724800 DOI: 10.1186/s12882-020-02152-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the most common cause of mortality in pediatric chronic kidney disease (CKD) patients. Left ventricular (LV) hypertrophy (LVH) is associated with LV diastolic dysfunction (LVDD) development and is used as an early marker of CVD in pediatric CKD. This study aimed to assess the prevalence and risk factors of LVDD and the association between LVH and LVDD in Korean pediatric CKD patients. Methods Data were collected using the baseline data of the Korean cohort study for outcome in patients with pediatric chronic kidney disease, a nationwide, 10-year, prospective, observational cohort study of pediatric CKD. A total of 244 patients were included in the final analysis. Two-dimensional echocardiography and tissue Doppler images were used to evaluate LVH and LVDD. LVH was defined as an LV mass index (LVMI) ≥38 g/m2.7 and LV-wall thickness z-score > 1.64. LVDD was defined as a mitral peak velocity of early filling to early diastolic mitral annular velocity (E/E’) > 14. Univariate and multivariate logistic regression analyses were performed to evaluate risk factors of LVDD. Results In this study, the male-to-female ratio was 2.2 (168:76) and median age was 11.2 years. The average estimated glomerular filtration rate was 57.4 ml/min/1.73 m2, and no patients received renal replacement therapy. The mean value of LVMI and E/E’ was 37.0 g/m2.7 and 7.4, respectively. The prevalence of LVH was 40.1 and 17.4% by LVMI ≥38 g/m2.7 and LV-wall thickness z-score, respectively. The prevalence of LVDD was 4.5%, and patients with LVH showed greater risk of LVDD (odds ratio 7.3, p = 0.012). In the univariate analysis, young age, low hemoglobin level, higher LVMI, and higher LV-wall thickness z-score were associated with LVDD. In the multivariate analysis, young age, low hemoglobin level, and higher LV-wall thickness z-score were independently associated with LVDD. Conclusion This study shows that LVH patients have a greater risk of LVDD and that anemia is the only modifiable risk factor for LVDD in Korean pediatric CKD patients.
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Affiliation(s)
- Jeong Yeon Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yeonhee Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hyun Jin Choi
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Chungcheongbuk-do, South Korea
| | - Kyoung Hee Han
- Department of Pediatrics, Jeju University Hospital, Jeju, South Korea
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, South Korea
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Severance Children's Hospital, Seoul, South Korea
| | - Joo Hoon Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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9
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Abstract
Fibroblast growth factor 23 (FGF23) is a hormone with a central role in the regulation of phosphate homeostasis. This regulation is accomplished by the coordinated modulation of renal phosphate handling, vitamin D metabolism and parathyroid hormone secretion. Patients with kidney disease have increased circulating levels of FGF23 and in other patient populations and in healthy individuals, FGF23 levels also rise following an increase in dietary phosphate intake. Maladaptive increases in FGF23 have a detrimental effect on several organs and tissues and, importantly, these pathological changes most likely contribute to increased morbidity and mortality. For example, in the context of heart disease, FGF23 is involved in the development of pathological hypertrophy that can lead to congestive heart failure. Increased FGF23 concentrations can also lead to microcirculatory changes, in particular reduced vasodilatory capacity, and collectively these cardiovascular changes can compromise tissue perfusion. In addition, FGF23 is associated with inflammation and an increased risk of infection; other potentially detrimental effects of FGF23 are likely to emerge in the future. Most importantly, recent insights demonstrate that FGF23 can be therapeutically targeted, which holds promise for the treatment of many patients in a variety of clinical settings.
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10
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Ferreira GD, Simões JA, Senaratna C, Pati S, Timm PF, Batista SR, Nunes BP. Physiological markers and multimorbidity: A systematic review. JOURNAL OF COMORBIDITY 2018; 8:2235042X18806986. [PMID: 30364915 PMCID: PMC6201184 DOI: 10.1177/2235042x18806986] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/07/2018] [Indexed: 01/08/2023]
Abstract
Background: Multimorbidity is the co-occurrence of two or more diseases in the same
individual. One method to identify this condition at an early stage is the
use of specific markers for various combinations of morbidities.
Nonetheless, evidence related to physiological markers in multimorbidity is
limited. Objective: The aim was to perform a systematic review to identify physiological markers
associated with multimorbidity. Design: Articles available on PubMed, Register of Controlled Trials, Academic Search
Premier, CINAHL, Scopus, SocINDEX, Web of Science, LILACS, and SciELO, from
their inception to May 2018, were systematically searched and reviewed. The
project was registered in PROSPERO under the number CRD42017055522. Results: The systematic search identified 922 papers. After evaluation, 18 articles
were included in the full review reporting at least one physiological marker
in coexisting diseases or which are strongly associated with the presence of
multimorbidity in the future. Only five of these studies examined
multimorbidity in general, identifying five physiological markers associated
with multimorbidity, namely, dehydroepiandrosterone sulfate (DHEAS),
interleukin 6 (IL-6), C-reactive protein (CRP), lipoprotein (Lp), and
cystatin C (Cyst-C). Conclusions: There is a paucity of studies related to physiological markers in
multimorbidity. DHEAS, IL-6, CRP, Lp, and Cyst-C could be the initial focus
for further investigation of physiological markers related to
multimorbidity.
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Affiliation(s)
- Gustavo Dias Ferreira
- Department of Physiology and Pharmacology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Chamara Senaratna
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Australia.,Department of Comunity Medicine, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | - Sanghamitra Pati
- ICMR Regional Medical Research Centre, Department of Health Research, Bhubaneswar, Odisha, India
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11
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Schneider MP, Scheppach JB, Raff U, Toncar S, Ritter C, Klink T, Störk S, Wanner C, Schlieper G, Saritas T, Reinartz SD, Floege J, Friedrich N, Janka R, Uder M, Schmieder RE, Eckardt KU. Left Ventricular Structure in Patients With Mild-to-Moderate CKD-a Magnetic Resonance Imaging Study. Kidney Int Rep 2018; 4:267-274. [PMID: 30775623 PMCID: PMC6365352 DOI: 10.1016/j.ekir.2018.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/23/2018] [Accepted: 10/02/2018] [Indexed: 01/19/2023] Open
Abstract
Introduction The high burden of left ventricular (LV) abnormalities in patients with advanced chronic kidney disease (CKD) is well established. However, less is known about the prevalence, patterns, and determinants of LV abnormalities in patients with early CKD. Methods We examined LV structure in 290 patients with a median estimated glomerular filtration rate (eGFR) of 51 ml/min per 1.73 m2 by magnetic resonance imaging (MRI). We explored associations with clinical and hemodynamic parameters, hydration (bioimpedance), endothelial function, inflammation (including C-reactive protein and tumor necrosis factor−α and its soluble receptors) and mineral bone disease (MBD) markers (including vitamin D, parathyroid hormone, α-klotho and fibroblast growth factor−23). Results Normal geometry was found in 56% of patients, dilation in 4%, concentric remodeling in 10%, and LV hypertrophy in 29%. Linear regression analysis revealed that greater LV mass was independently associated with male sex, greater body mass index (BMI), and higher 24-hour systolic blood pressure (24-hour SBP). Concentric remodeling was independently associated with age, male sex, higher 24-hour SBP, and greater hemoglobin levels. Surprisingly, neither hydration status, nor endothelial function, nor any of the inflammatory or MBD parameters added significantly to these models. Conclusion Abnormal LV structure was found in almost one-half of the patients. Reducing BMI and 24-hour SBP and avoiding high hemoglobin concentrations appear to be the key factors to prevent abnormal LV remodeling in patients with mild-to-moderate CKD.
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Affiliation(s)
- Markus P Schneider
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Nephrology and Hypertension, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
| | - Johannes B Scheppach
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulrike Raff
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Toncar
- Division of Nephrology, Department of Medicine, University of Würzburg, Würzburg, Germany
| | - Christian Ritter
- Department of Diagnostic and Interventional Radiology, University Medicine Göttingen, Göttingen, Germany
| | - Thorsten Klink
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and Department of Medicine I, Cardiology, University Hospital Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University of Würzburg, Würzburg, Germany
| | - Georg Schlieper
- Division of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Turgay Saritas
- Division of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian D Reinartz
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Nele Friedrich
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Rolf Janka
- Department of Radiology, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Uder
- Department of Radiology, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
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12
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The role of fibroblast growth factor 23 and Klotho in uremic cardiomyopathy. Curr Opin Nephrol Hypertens 2018; 25:314-24. [PMID: 27219043 DOI: 10.1097/mnh.0000000000000231] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In chronic kidney disease (CKD), multiple factors contribute to the development of cardiac hypertrophy by directly targeting the heart or indirectly by inducing systemic changes such as hypertension, anemia, and inflammation. Furthermore, disturbances in phosphate metabolism have been identified as nonclassical risk factors for cardiovascular mortality in these patients. With declining kidney function, the physiologic regulators of phosphate homeostasis undergo changes in their activity as well as their circulating levels, thus potentially contributing to cardiac hypertrophy once they are out of balance. Recently, two of these phosphate regulators, fibroblast growth factor 23 (FGF23) and Klotho, have been shown to affect cardiac remodeling, thereby unveiling a novel pathomechanism of cardiac hypertrophy in CKD. Here we discuss the potential direct versus indirect effects of FGF23 and the soluble form of Klotho on the heart, and their crosstalk in the regulation of cardiac hypertrophy. RECENT FINDINGS In models of CKD, FGF23 can directly target cardiac myocytes via FGF receptor 4 and induce cardiac hypertrophy in a blood pressure-independent manner. Soluble Klotho may directly target the heart via an unknown receptor thereby protecting the myocardium from pathologic stress stimuli that are associated with CKD, such as uremic toxins or FGF23. SUMMARY Elevated serum levels of FGF23 and reduced serum levels of soluble Klotho contribute to uremic cardiomyopathy in a synergistic manner.
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Mitsnefes MM, Betoko A, Schneider MF, Salusky IB, Wolf MS, Jüppner H, Warady BA, Furth SL, Portale AA. FGF23 and Left Ventricular Hypertrophy in Children with CKD. Clin J Am Soc Nephrol 2018; 13:45-52. [PMID: 29025789 PMCID: PMC5753303 DOI: 10.2215/cjn.02110217] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 08/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES High plasma concentration of fibroblast growth factor 23 (FGF23) is a risk factor for left ventricular hypertrophy (LVH) in adults with CKD, and induces myocardial hypertrophy in experimental CKD. We hypothesized that high FGF23 levels associate with a higher prevalence of LVH in children with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed echocardiograms and measured plasma C-terminal FGF23 concentrations in 587 children with mild-to-moderate CKD enrolled in the Chronic Kidney Disease in Children (CKiD) study. We used linear and logistic regression to analyze the association of plasma FGF23 with left ventricular mass index (LVMI) and LVH (LVMI ≥95th percentile), adjusted for demographics, body mass index, eGFR, and CKD-specific factors. We also examined the relationship between FGF23 and LVH by eGFR level. RESULTS Median age was 12 years (interquartile range, 8-15) and eGFR was 50 ml/min per 1.73 m2 (interquartile range, 38-64). Overall prevalence of LVH was 11%. After adjustment for demographics and body mass index, the odds of having LVH was higher by 2.53 (95% confidence interval, 1.28 to 4.97; P<0.01) in participants with FGF23 concentrations ≥170 RU/ml compared with those with FGF23<100 RU/ml, but this association was attenuated after full adjustment. Among participants with eGFR≥45 ml/min per 1.73 m2, the prevalence of LVH was 5.4%, 11.2%, and 15.3% for those with FGF23 <100 RU/ml, 100-169 RU/ml, and ≥170 RU/ml, respectively (Ptrend=0.01). When eGFR was ≥45 ml/min per 1.73 m2, higher FGF23 concentrations were independently associated with LVH (fully adjusted odds ratio, 3.08 in the highest versus lowest FGF23 category; 95% confidence interval, 1.02 to 9.24; P<0.05; fully adjusted odds ratio, 2.02 per doubling of FGF23; 95% confidence interval, 1.29 to 3.17; P<0.01). By contrast, in participants with eGFR<45 ml/min per 1.73 m2, FGF23 did not associate with LVH. CONCLUSIONS Plasma FGF23 concentration ≥170 RU/ml is an independent predictor of LVH in children with eGFR≥45 ml/min per 1.73 m2.
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Affiliation(s)
- Mark M. Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Aisha Betoko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael F. Schneider
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Isidro B. Salusky
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Myles Selig Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Harald Jüppner
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bradley A. Warady
- Section of Nephrology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Susan L. Furth
- Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Anthony A. Portale
- Division of Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, California
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Tranæus Lindblad Y, Olauson H, Vavilis G, Hammar U, Herthelius M, Axelsson J, Bárány P. The FGF23-Klotho axis and cardiac tissue Doppler imaging in pediatric chronic kidney disease-a prospective cohort study. Pediatr Nephrol 2018; 33:147-157. [PMID: 28795324 PMCID: PMC5700222 DOI: 10.1007/s00467-017-3766-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/13/2017] [Accepted: 07/14/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Chronic kidney disease-associated mineral bone disorder (CKD-MBD) is common in pediatric kidney disease patients and a risk factor for future cardiovascular disease (CVD). Fibroblast growth factor-23 (FGF23) and Klotho are novel key players in CKD-MBD, and has been suggested to be involved in the development of CVD. METHODS This prospective cohort study included 74 pediatric patients; 31 with CKD (age range 0.8-18.8 years, glomerular filtration rate (GFR) range 9-68 mL/min/1.73 m2) and 43 transplanted patients (CKD-T; age range 3.3-17.7 years, GFR range 10-99 mL/min/1.73 m2) examined annually for 3 years. We assessed longitudinal patterns and predictors of FGF23 and soluble Klotho, as well as associations to cardiac remodeling and function using echocardiographic pulse wave Doppler (PWD) and color-coded tissue Doppler imaging (cc-TDI). RESULTS The prevalence of high FGF23 levels (≥95th percentile) was 60% in CKD and 42% in CKD-T patients, despite a low prevalence of hyperphosphatemia and normal Klotho levels. Low GFR at baseline was a predictor for high mean log FGF23 during follow-up in CKD and CKD-T patients (β = -0.2, p < 0.001). A high log FGF23 z-score longitudinally was borderline significantly associated with elevated left ventricular mass index (LVMI) in CKD patients (β = 1.8, p = 0.06). In addition, high log FGF23 (β = -0.43, p = 0.01) and low log Klotho (β = 0.44, p = 0.006) over time were associated with a worse left ventricular diastolic function (cc-TDI e'/a') in CKD-T patients. CONCLUSIONS In pediatric CKD and CKD-T patients, the FGF23 level increase and Klotho level decrease with progressing renal failure, despite well-controlled phosphate levels. Following adjustments, both high FGF23 and low Klotho levels were strongly associated with a worse left ventricular diastolic function longitudinally. The potential role of FGF23 and Klotho in cardiac morbidity in pediatric CKD requires further investigation.
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Affiliation(s)
- Ylva Tranæus Lindblad
- Division of Pediatrics, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. .,Astrid Lindgren Children's Hospital, Huddinge BUMM, Paradistorget 4, 5tr, S-141 47, Huddinge, Sweden. .,Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden.
| | - Hannes Olauson
- 0000 0004 1937 0626grid.4714.6Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Georgios Vavilis
- 0000 0000 9241 5705grid.24381.3cDivision of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Hammar
- 0000 0004 1937 0626grid.4714.6Institute of Environmental Medicine and Unit of Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Maria Herthelius
- 0000 0004 1937 0626grid.4714.6Division of Pediatrics, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden ,0000 0000 9241 5705grid.24381.3cDepartment of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Axelsson
- 0000 0000 9241 5705grid.24381.3cDepartment of Immunology, Karolinska University Hospital, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Peter Bárány
- 0000 0004 1937 0626grid.4714.6Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden ,0000 0000 9241 5705grid.24381.3cDepartment of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
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15
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Takashi Y, Kinoshita Y, Hori M, Ito N, Taguchi M, Fukumoto S. Patients with FGF23-related hypophosphatemic rickets/osteomalacia do not present with left ventricular hypertrophy. Endocr Res 2017; 42:132-137. [PMID: 27754732 DOI: 10.1080/07435800.2016.1242604] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Fibroblast growth factor 23 (FGF23) is a hormone regulating phosphate metabolism. Excessive actions of FGF23 cause several types of FGF23-related hypophosphatemic rickets/osteomalacia. Recently, it was reported that FGF23 levels were independently correlated with left ventricular hypertrophy (LVH) in patients with chronic kidney disease (CKD). In addition, FGF23 was also shown to cause cardiac hypertrophy directly acting on cardiomyocytes. However, there is no study indicating the correlation between FGF23 and LVH in adult patients with FGF23-related hypophosphatemic rickets/osteomalacia. Therefore, we examined the existence of LVH in these patients. MATERIALS AND METHODS We recruited consecutive 24 patients with FGF23-related hypophosphatemic diseases. Their serum intact FGF23 levels and the parameters associated with LVH, including left ventricular mass index (LVMI), relative wall thickness (RWT), Sokolow-Lyon voltage, and Cornell product, were measured. The correlations between FGF23 and these parameters were examined. RESULTS The participants did not show LVH on the whole. In addition, no significant correlation was observed by these examinations. CONCLUSION It seems unlikely that FGF23 levels are the apparent determinant of the cardiac mass in patients with FGF23-related hypophosphatemic rickets/osteomalacia.
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Affiliation(s)
- Yuichi Takashi
- a Division of Nephrology and Endocrinology , The University of Tokyo Hospital , Bunkyo-ku , Tokyo , Japan
| | - Yuka Kinoshita
- a Division of Nephrology and Endocrinology , The University of Tokyo Hospital , Bunkyo-ku , Tokyo , Japan
| | - Michiko Hori
- a Division of Nephrology and Endocrinology , The University of Tokyo Hospital , Bunkyo-ku , Tokyo , Japan
| | - Nobuaki Ito
- a Division of Nephrology and Endocrinology , The University of Tokyo Hospital , Bunkyo-ku , Tokyo , Japan
| | - Manabu Taguchi
- a Division of Nephrology and Endocrinology , The University of Tokyo Hospital , Bunkyo-ku , Tokyo , Japan
| | - Seiji Fukumoto
- a Division of Nephrology and Endocrinology , The University of Tokyo Hospital , Bunkyo-ku , Tokyo , Japan
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Nassiri AA, Hakemi MS, Safar-Pour R, Ahmadi A, Tohidi M, Kashani BS, Esfehani F, Alatab S. Association of serum intact fibroblast growth factor 23 with left ventricular mass and different echocardiographic findings in patients on hemodialysis. J Transl Int Med 2016; 4:135-141. [PMID: 28191535 DOI: 10.1515/jtim-2016-0030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine the association of fibroblast growth factor 23 (FGF23) with left ventricular hypertrophy (LVH) through the assessment of left ventricular (LV) mass and left ventricular mass index (LVMI) in patients on hemodialysis, this study was done. METHODS All patients on hemodialysis who are older than 18 years and in whom hemodialysis vintage was at least 6 months were enrolled. All patients were on hemodialysis thrice a week for 4 h using low-flux dialysis filters, polysulfone membranes, reverse osmosis purified water, and bicarbonate-base hemodialysis solution. The exclusion criteria were any respiratory illness or pulmonary infection, cigarette smoking, and the presence of pericarditis or pericardial effusion. Additionally, patients with a known coronary artery disease, any form of cardiac arrhythmias, any cardiomyopathy or severe valvular heart disease diagnosed by echocardiography, acute congestive heart failure (CHF), and acute myocardial infarction were not included. Echocardiography was conducted by an experienced operator for all the enrolled patients using the ACUSON SC2000™ ultrasound system transducer (Siemens), with a frequency bandwidth of: 1.5-3.5 MHz. Patients were considered to have LVH if the LVMI was greater than 134 g/m2 for men and greater than 110 g/m2 for women. RESULTS A total of 61 patients (19 female and 42 male) were enrolled to the study. Mean (± SD) age of the patients was 59.6 ± 13.1 years. The median duration of hemodialysis was 23 (range: 6-120) months. The median predialysis level of FGF23 was 1,977 pg/mL (range: 155-8,870). LVH was seen in 73.8% of the patients (n = 45) and of them 66.7% were male. There was a statistically significant direct correlation between FGF23 and left ventricle diameter in end systole (LVDs) (r = 0.29, P = 0.027). However, the association of FGF23 with LV mass, LVMI, and left ventricular ejection fraction (LVEF) was not significant. CONCLUSION This study does not show the correlation between FGF23 and LV mass in stable hemodialysis patients.
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Affiliation(s)
- Amir Ahmad Nassiri
- Department of Nephrology, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)
| | - Monir Sadat Hakemi
- Department of Nephrology, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran (Islamic Republic of)
| | - Reza Safar-Pour
- Department of Nephrology, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)
| | - Ali Ahmadi
- Department of Epidemiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)
| | - Maryam Tohidi
- Department of Pathology, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)
| | - Babak Sharif Kashani
- Department of Cardiology, Massih-Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)
| | - Fatemeh Esfehani
- Research Center, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran (Islamic Republic of)
| | - Soudabeh Alatab
- Department of Nephrology, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)
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Abstract
Alpha-Klotho (αKlotho) protein is encoded by the gene, Klotho, and functions as a coreceptor for endocrine fibroblast growth factor-23. The extracellular domain of αKlotho is cleaved by secretases and released into the circulation where it is called soluble αKlotho. Soluble αKlotho in the circulation starts to decline in chronic kidney disease (CKD) stage 2 and urinary αKlotho in even earlier CKD stage 1. Therefore soluble αKlotho is an early and sensitive marker of decline in kidney function. Preclinical data from numerous animal experiments support αKlotho deficiency as a pathogenic factor for CKD progression and extrarenal CKD complications including cardiac and vascular disease, hyperparathyroidism, and disturbed mineral metabolism. αKlotho deficiency induces cell senescence and renders cells susceptible to apoptosis induced by a variety of cellular insults including oxidative stress. αKlotho deficiency also leads to defective autophagy and angiogenesis and promotes fibrosis in the kidney and heart. Most importantly, prevention of αKlotho decline, upregulation of endogenous αKlotho production, or direct supplementation of soluble αKlotho are all associated with attenuation of renal fibrosis, retardation of CKD progression, improvement of mineral metabolism, amelioration of cardiac function and morphometry, and alleviation of vascular calcification in CKD. Therefore in rodents, αKlotho is not only a diagnostic and prognostic marker for CKD but the enhancement of endogenous or supplement of exogenous αKlotho are promising therapeutic strategies to prevent, retard, and decrease the comorbidity burden of CKD.
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Affiliation(s)
- J A Neyra
- University of Texas Southwestern Medical Center, Dallas, TX, United States; Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - M C Hu
- University of Texas Southwestern Medical Center, Dallas, TX, United States; Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, United States.
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